Program Specialist - Purchase Preferred Care

Job DetailsLevel: ExperiencedJob Location: Longview, WA 98632Salary Range: $27.15 - $31.25 HourlyPOSITION TITLE: Program Specialist – Purchase Preferred Care DEPARTMENT: Purchase Preferred Care LOCATION: Longview, Washington REPORTS TO: Program Manager, PRC STATUS: Hourly; Full-Time WAGE RANGE: $27.15 - $31.25 per hour CLOSING DATE: Open Until Filled (First Review 8/18/2026)   ***If you are an American Indian/Alaska Native and/or a Veteran and would like this to be considered a preference in hiring, please upload documentation with your resume and cover letter. Acceptable documentation includes a Tribal Enrollment card, a letter from your Tribe stating your enrollment, or BIA 4432 and/or DD214.***   Position Summary: Coordinates Purchased/Referred Care (PRC) services by determining patient eligibility, reviewing and processing referrals and prior authorizations, coordinating access to healthcare services, and processing claims for payment and denials in accordance with Cowlitz Indian Tribe Health & Human Services (CITHHS) policies and procedures and PRC program requirements. Educates members and providers regarding PRC eligibility, alternate resources, and program requirements to ensure timely access to care. Maintains accurate records, protects confidential information (HIPAA), and provides exceptional customer service while supporting the mission, vision, and values of the Cowlitz Indian Tribe. This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.   Essential Duties & Responsibilities: Authorizes medical, dental, and vision services for eligible medical beneficiaries and maintains records of all services purchased and payments made. Assists and educates clients on program registration and enrollment processes, including completing applications, meeting program requirements, and accessing alternate resources. Reviews and determines client eligibility for PRC program services and coordinates access to available benefits to ensure clients receive services and resources for which they qualify. Maintains billing and payment records, communicates with clients and providers on payment application procedures, claims processing, and status updates. Maintains accurate patient records to include eligible data, invoices of all medical bills paid, and referrals. Responds to requests for information from vendors concerning payment of bills promptly and in accordance with tribal policies and procedures. Participates in training and ongoing program evaluation to ensure PRC program is meeting the needs of clients. Provides education to clients, vendors, and staff on PRC policies, appeal processes, alternate resources, and eligibility requirements. Processes and monitors prior authorizations; coordinates with patients and providers to obtain required information and follows cases through payment completion. Tracks, records, and reports on client and program data as requested. Reviews, prepares, and submits Purchased/Referred Care (PRC) claims for payment in accordance with CITHHS regulations, Manages incoming telephone and voicemail communications by screening inquiries, determining needs, and routing calls and messages to the appropriate personnel or department. Participates in staff meetings as needed. Adapts to changes in safety protocols and procedures. Completes Information Security System Awareness (ISSA) training as required. Contributes to a team effort and accomplishes related results as required. Performs other duties as assigned.   Knowledge, Skills, and Abilities: Knowledge of traditional forms of government and tribal customs and traditions. Knowledge of business English, proper spelling, grammar, punctuation, and basic arithmetic. Knowledge of basic medical terminology preferred. Knowledge of electronic health records (EHR) and patient registration systems. Knowledge of policies and procedures related to HIPAA, Medicare, Medicaid, and insurance programs. Skill in operating various word-processing, spreadsheet, and database software programs in a Windows environment, including electronic health care systems. Skill in reviewing claims, billing information, payment documentation, and numerical data for accuracy. Skill in providing professional, respectful, and culturally appropriate customer service to providers, Tribal members, and community partners. Ability to interpret and apply PRC eligibility requirements, policies, regulations, and procedures. Ability to review detailed medical, insurance, billing, and claims information for accuracy and completeness. Ability to research and resolve discrepancies involving eligibility, referrals, authorizations, claims, and payments. Ability to maintain confidentiality. Ability to interact and maintain good working relationships with individuals of varying social and cultural backgrounds. Ability to carry out instructions furnished in verbal or written format. Ability to communicate efficiently and effectively both verbally and in writing. Ability to handle multiple tasks and meet deadlines. Ability to exercise independent judgment. QualificationsMinimum Qualifications: High School Diploma/GED; associate’s degree preferred. Five (5) years of related experience. A combination of relevant education and related work experience may be considered. A valid driver’s license is required when driving vehicles for work-related purposes. Obtain and maintain BLS/CPR and AED certifications. Must be able to successfully pass a background screening/investigation according to the established requirements below.   Tribal preference in accordance with the Cowlitz Indian Tribe Code and CIT Employee Policies and Procedures Handbook shall apply to all positions. All positions are required to adhere to CIT’s established safety policies regarding vaccine requirements and personal protective equipment (PPE).   Background Investigation Requirements: Pre-employment drug screen. Reference checks, education and employment verification. Federal, state, and/or tribal criminal history and sanction checks including fingerprint verification. Has not been found guilty of, charged with, received a deferred sentence, received a conditional discharge of, or entered a plea of not contest to, or entered a plea of guilty to any one felony or misdemeanor crimes of violence, sexual assault, molestation, exploitation or sexual contact; prostitution; or crimes committed against person(s) or children.   Physical Demands: While performing the duties of this job, the employee regularly is required to sit; use hands to finger, handle, or feel; and talk or hear. The employee occasionally is required to stand; walk; and reach with hands and arms. The employee is occasionally required to lift up to 20 pounds. Specific vision abilities required by this job include close vision and clarity of vision at long distance.   Work Environment: Work is generally performed in an office/clinical setting with a moderate noise level. Employees may be exposed to unpleasant odors, bodily fluids, bloodborne pathogens, and infectious diseases. Situations occur where PPE (personal protective equipment) is needed. May come in contact with hostile, violent, or offensive individuals. Evening and/or weekend work may be required. Tight time constraints and multiple demands are common.